Evolving Understanding of Rosacea Calls for Fresh Thinking and New Treatment Approaches

Despite the fact that dermatologists’ knowledge of rosacea has evolved, they still follow treatment protocols aligned with the now outdated subtypes.

Sixteen million Americans suffer with rosacea.1 For years, dermatologists treated 4 distinct subtypes of rosacea—essentially dealing with the disease as a collection of conditions characterized by different symptoms and defined by different pathobiological mechanisms. The more common clinical variants—vascular, inflammatory, rhinophymatous, and ocular rosacea—are still used in grading patients both in the clinic and in research. In addition, the diagnosis of granulomatous rosacea remains an enigma for many dermatologists.

Since 2002, when the National Rosacea Society (NRS) published accepted recommendations for treating the condition, it has been understood that the majority of rosacea patients suffer from a combination of different subtypes.2

In fact, a 2004 survey of more than 1200 patients found that 72% experienced some kind of progression and 77% experienced more than one subtype at a time.3

New research shows that rosacea’s different symptoms and clinical presentations may all be part of a continuum of subclinical inflammation that appears detectable histologically and biochemically.4-7

Yet, although rosacea’s different phenotypes can appear in different combinations and at different times, they may all be manifestations of the same underlying inflammatory continuum4-6 and individual cases may progress in severity and worsen to include additional phenotypes.8,9

Last year, an NRS panel of experts10 concluded that the old subtypes do not adequately represent the diagnostic categories because many rosacea patients exhibit transient and progressive signs and symptoms. It outlined 2 diagnostic, 4 major, and 3 secondary phenotypes. Similarly, recent studies have identified associations between rosacea and an increased risk for a variety of systemic disorders.11

However, despite the fact that our knowledge of rosacea has evolved, dermatologists still follow treatment protocols aligned with the now outdated subtypes.

Time to Revisit Treatment Regimens

If rosacea truly is a continuum of inflammation, it may be time to reconsider the approach that dermatologists use to treat it. Why? Because current treatment protocols tend to address the different symptoms that historically defined the classical subtypes that have now been shown to be inconsistent to the essence of the underlying continuum.

A new classification system published by the NRS panel of experts identifies 2 diagnostic, 4 major, and 3 secondary phenotypes of rosacea, all of which appear to be interrelated.10

Diagnostic Phenotypes

The presence of 1 of the following diagnostic phenotypes may lead to a diagnosis of rosacea, after ruling out possible differential diagnoses:

Fixed centrofacial erythema. Persistent redness of the facial skin in a characteristic pattern is the most common sign of rosacea.10

Phymatous changes.These may include skin thickening or fibrosis, patulous follicles, glandular hypoplasia, and a bulbous appearance of the nose.10